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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200274
Report Date: 09/19/2024
Date Signed: 09/19/2024 05:07:02 PM

Document Has Been Signed on 09/19/2024 05:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:BRISTOL PLACEFACILITY NUMBER:
019200274
ADMINISTRATOR/
DIRECTOR:		VANESSA (KRUSE) RODRIGUEZFACILITY TYPE:
735
ADDRESS:5242 BRISTOL PLTELEPHONE:
(510) 792-5450
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY: 3CENSUS: 3DATE:
09/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:10 PM
MET WITH:Stephanie GartkeTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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On this day at around 2:10pm, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and was met by staff Preston Hart. LPA explained to Hart the purpose of the visit. The Administrator has left for the day but was informed about the visit via telephone. The Administrator authorized staff Stephanie Gartke to sign the report.

At around 2:15 pm, LPA inspected the facility inside and out including but not limited to 3 client rooms, 2 bathrooms, dining area, kitchen and backyard. Hot water measured at 94.5 degrees Fahrenheit in the kitchen and client shower room. Non skid mats and grab bars were observed in the shower room. There were smoke detectors observed in all client rooms. Fire extinguisher in the kitchen was observed full and last inspected on 2/11/2024. Medications were observed locked in the hallway cabinet. Sufficient supply of perishable and non perishable foods were observed.

At 2:55 pm, LPA reviewed 3 client files. LPA was unable to review staff files and P&I log as the Administrator has left for the day and not one among the staff present have access to said records.

The following deficiencies were observed:
  • hot water measured at 94.5 Fahrenheit both in the kitchen and client bathroom
  • expired emergency non perishable foods in the garage
  • staff records were not available during the visit

Deficiencies were cited per Title 22 California Code of Regulations (refer to Lic 809D). Exit interview was conducted with Gartke and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 09/19/2024 05:07 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 09/19/2024 at 04:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BRISTOL PLACE
FACILITY NUMBER: 019200274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having hot water at 94.5 Fahrenheit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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Administrator will have hot water temperature adjusted between 105-120 Fahrenheit.
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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All staff records were not accessible to LPA during the visit.
POC Due Date: 09/30/2024
Plan of Correction
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The Administrator will submit a plan on how to ensure all records are available to CCL anytime and submit plans to CCL by 9/30/2024.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024


LIC809 (FAS) - (06/04)
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